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Traumatic brain injury (TBI) causes deficits in executive function (EF), as well as problems in behavioural and emotional self-regulation. Neurological music therapy may aid these aspects of recovery. We performed a cross-over randomized controlled trial where 40 persons with moderate-severe TBI received a 3-month neurological music therapy intervention (2 times/week, 60 min/session), either during the first (AB, n = 20) or second (BA, n = 20) half of a 6-month follow-up period. The evidence from this RCT previously demonstrated that music therapy enhanced general EF and set shifting. In the current study, outcome was assessed with self-report and caregiver-report questionnaires performed at baseline, 3-month, 6-month, and 18-month stages. The results showed that the self-reported Behavioural Regulation Index of the Behaviour Rating Inventory of Executive Function (BRIEF-A) improved more in the AB than BA group from baseline to 3-month stage and the effect was maintained in the 6-month follow-up. No changes in mood or quality of life questionnaires were observed. However, a qualitative content analysis of the feedback revealed that many participants experienced the intervention as helpful in terms of emotional well-being and activity. Our results suggest that music therapy has a positive effect on everyday behavioural regulation skills after TBI.

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Traumatic brain injury (TBI) is characterized by a complex pattern of abnormalities in resting-state functional connectivity (rsFC) and network dysfunction, which can potentially be ameliorated by rehabilitation. In our previous randomized controlled trial, we found that a 3-month neurological music therapy intervention enhanced executive function (EF) and increased grey matter volume in the right inferior frontal gyrus (IFG) in patients with moderate-to-severe TBI (N = 40). Extending this study, we performed longitudinal rsFC analyses of resting-state fMRI data using a ROI-to-ROI approach assessing within-network and between-network rsFC in the frontoparietal (FPN), dorsal attention (DAN), default mode (DMN), and salience (SAL) networks, which all have been associated with cognitive impairment after TBI. We also performed a seed-based connectivity analysis between the right IFG and whole-brain rsFC. The results showed that neurological music therapy increased the coupling between the FPN and DAN as well as between these networks and primary sensory networks. By contrast, the DMN was less connected with sensory networks after the intervention. Similarly, there was a shift towards a less connected state within the FPN and SAL networks, which are typically hyperconnected following TBI. Improvements in EF were correlated with rsFC within the FPN and between the DMN and sensorimotor networks. Finally, in the seed-based connectivity analysis, the right IFG showed increased rsFC with the right inferior parietal and left frontoparietal (Rolandic operculum) regions. Together, these results indicate that the rehabilitative effects of neurological music therapy after TBI are underpinned by a pattern of within- and between-network connectivity changes in cognitive networks as well as increased connectivity between frontal and parietal regions associated with music processing.

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BACKGROUND: The straight leg raise (SLR) is the most commonly applied physical tests on patients with sciatica, but the sensitivity and specificity ratings for disc hernia and neural compression leave areas for improvement. Hip internal rotation tensions the lumbosacral nerve roots and ankle dorsiflexion tensions the sciatic nerve along its course. We added these movements to the SLR (extended SLR = ESLR) as structural differentiators and tested inter-rater reliability in patients with LBP, with and without sciatica. METHODS: Forty subjects were recruited to the study by the study controller (SC), 20 in the sciatic group and in the control group. Two independent examiners (E1&E2) performed the ESLR and did not communicate to the subjects other than needed to determine the outcome of the ESLR. First, SLR was performed traditionally until first responses were evoked. At this hip flexion angle, a location-specific structural differentiation was performed to confirm whether the emerged responses were of neural origin. Cohen's Kappa score (CK) for interrater reliability was calculated for ESLR result in detection of sciatic patients. Also, the examiners' ESLR results were compared to the traditional SLR results. RESULTS: The interrater agreement between Examiner 1 and Examiner 2 for the ESLR was 0.85 (p < 0.001, 95%CI: 0.71-0.99) translating to almost perfect agreement as measured by Cohen's Kappa When the ESLR was compared to the traditional SLR, the overall agreement rate was 75% (30/40). Kappa values between the traditional SLR and the E1's or E2's ESLR results were 0.50 (p < 0.0001; 95%CI 0.27-0.73) and 0.54 (p < 0.0001; 95%CI 0.30-0.77), respectively. CONCLUSIONS: ESLR with the addition of location-specific structural differentiation is a reliable and repeatable tool in discerning neural symptoms from musculoskeletal in patients with radiating low back pain. We recommend adding these movements to the standard SLR with aim of improving diagnostic ability.

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Objective: Dance is a versatile and multimodal rehabilitation method, which may be useful also in traumatic brain injury (TBI) rehabilitation. Here, we assessed the feasibility and preliminary effects of a novel dance-based intervention called Dual-Assisted Dance Rehabilitation (DARE).Method: This is a feasibility study with a cross-over design where 11 persons with severe/extremely severe TBI received a 12-week (2 times/week) DARE program. Motor and neuropsychological tests and questionnaires measuring mood, executive functions, and quality of life were performed at baseline, 3-month, and 6-month stage. Self-perceived benefits were assessed with a post-intervention questionnaire.Results: Acceptability of and adherence to DARE were encouraging: 91% were fully consistent with protocol, and adherence to DARE sessions was 83-100%. Pre-post treatment effects sizes were medium-large for self-reported depression (BDI-II: d = 1.19-1.74) and executive deficits (BRIEF-A: d = 0.43-1.09) and for test-assessed trunk movement control (TIS: d = 0.47-0.76) and cognitive functioning (WAIS-IV subtests: d = 0.34-0.89). Other outcome measures did not show similar positive effect sizes. Self-perceived benefits were largest for mobility and cognition.Conclusion: Dance-based rehabilitation is a feasible and promising method in severe TBI and its efficacy should be assessed with a larger clinical trial.

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Traumatic brain injury (TBI) causes lifelong cognitive deficits, particularly impairments of executive functioning (EF). Musical training and music-based rehabilitation have been shown to enhance cognitive functioning and neuroplasticity, but the potential rehabilitative effects of music in TBI are still largely unknown. The aim of the present crossover randomized controlled trial (RCT) was to determine the clinical efficacy of music therapy on cognitive functioning in TBI and to explore its neural basis. Using an AB/BA design, 40 patients with moderate or severe TBI were randomized to receive a 3-month neurological music therapy intervention either during the first (AB, n = 20) or second (BA, n = 20) half of a 6-month follow-up period. Neuropsychological and motor testing and magnetic resonance imaging (MRI) were performed at baseline and at the 3-month and 6-month stage. Thirty-nine subjects who participated in baseline measurement were included in an intention-to-treat analysis using multiple imputation. Results showed that general EF (as indicated by the Frontal Assessment Battery [FAB]) and set shifting improved more in the AB group than in the BA group over the first 3-month period and the effect on general EF was maintained in the 6-month follow-up. Voxel-based morphometry (VBM) analysis of the structural MRI data indicated that gray matter volume (GMV) in the right inferior frontal gyrus (IFG) increased significantly in both groups during the intervention versus control period, which also correlated with cognitive improvement in set shifting. These findings suggest that neurological music therapy enhances EF and induces fine-grained neuroanatomical changes in prefrontal areas.

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BACKGROUND: Traumatic brain injury (TBI) is a major health problem that often requires intensive and long-term rehabilitation. OBJECTIVE: The aim of this study was to determine whether rehabilitative digital gaming facilitates cognitive functioning and general well-being in people with TBI. METHODS: A total of 90 Finnish-speaking adults with TBI (18-65 years) were recruited from an outpatient neuroscience clinic. The participants were randomly allocated to one of the three groups: a rehabilitation gaming group (n=29, intervention), an entertainment gaming group (n=29, active control), or a passive control group (n=32). The gaming groups were instructed to engage in gaming for a minimum of 30 min per day for 8 weeks. Primary and secondary outcomes were measured at three time points: before the intervention, after the intervention, and 3 months following the intervention. The primary outcome was cognitive status measured by processing speed and visuomotor tasks (The Trail Making Test; Wechsler Adult Intelligence Scale-Fourth Edition, WAIS-IV, symbol search, coding, and cancellation tasks). Secondary outcomes were attention and executive functions (Simon task), working memory (WAIS-IV digit span and Paced Auditory Serial Addition Test, PASAT), depression (Patient Health Questionnaire-9), self-efficacy (General Self-efficacy Scale), and executive functions (Behavior Rating Inventory of Executive Function-Adult Version). Feasibility information was assessed (acceptability, measurement instruments filled, dropouts, adherence, usability, satisfaction, and possible future use). Cognitive measurements were conducted in face-to-face interviews by trained psychologists, and questionnaires were self-administered. RESULTS: The effects of rehabilitation gaming did not significantly differ from the effects of entertainment gaming or being in a passive control group. For primary outcomes and PASAT tests, the participants in all three groups showed overall improvement in test scores across the three measurement points. However, depression scores increased significantly between baseline and after 8 weeks and between baseline and after 3 months in the rehabilitative gaming group. No differences were found in patients' self-efficacy between the three measuring points in any of the groups. Participants did use the games (rehabilitation group: 93%, 27/29; entertainment group 100%, 29/29). Games were seen as a usable intervention (rehabilitation group: 70%, 14/29; entertainment group: 83%, 20/29). The rehabilitation group was less satisfied with the gaming intervention (68%, 13/29 vs 83%, 20/29), but they were more willing to use the game after the intervention period (76%, 16/29 vs 63%, 15/29). Total time spent on gaming during the intervention period was low (15.22 hour rehabilitation gaming group, 19.22 hour entertainment gaming group). CONCLUSIONS: We did not find differences between the groups in improvement in the outcome measures. The improvements in test performance by all three groups may reflect rehearsal effects. Entertainment gaming had elements that could be considered when rehabilitative games are designed for, implemented in, and assessed in larger clinical trials for persons with TBI. TRIAL REGISTRATION: ClinicalTrials.gov NCT02425527; https://clinicaltrials.gov/ct2/show/NCT02425527 (Archived by WebCite at http://www.webcitation.org/6esKI1uDH).

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PURPOSE: We examined the safety profile and usability of an integrated advanced robotic device and telecare system to promote medication adherence for elderly home-care patients. METHODS: There were two phases. Phase I aimed to verify under controlled conditions in a single nursing home (n = 17 patients) that no robotic malfunctions would hinder the device's safe use. Phase II involved home-care patients from 3 sites (n = 27) who were on long-term medication. On-time dispensing and missed doses were recorded by the robotic system. Patients' and nurses' experiences were assessed with structured interviews. FINDINGS: The 17 nursing home patients had 457 total days using the device (Phase I; mean, 26.9 per patient). On-time sachet retrieval occurred with 97.7% of the alerts, and no medication doses were missed. At baseline, Phase II home-dwelling patients reported difficulty remembering to take their medicines (23%), and 18% missed at least 2 doses per week. Most Phase II patients (78%) lived alone. The device delivered and patients retrieved medicine sachets for 99% of the alerts. All patients and 96% of nurses reported the device was easy to use. IMPLICATIONS: This trial demonstrated the safety profile and usability of an in-home advanced robotic device and telecare system and its acceptability to patients and nurses. It supports individualized patient dosing schedules, patient-provider communications, and on-time, in-home medication delivery to promote adherence. Real time dose-by-dose monitoring and communication with providers if a dose is missed provide oversight generally not seen in home care.

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BACKGROUND: Traumatic brain injury (TBI) is a critical public health problem. The recovery process for people with TBI is typically slow and dependent on complex and intensive assisted rehabilitation programs. OBJECTIVE: To evaluate the effects and feasibility of digital games for cognitive functioning and general well-being among people with traumatic brain injury. METHODS: This is a single-site feasibility study conducted in Finland, which uses a pragmatic, randomized controlled trial with three arms, and will recruit patients from the Turku University Hospital, Division of Clinical Neurosciences in Finland. Participants must meet the following inclusion criteria: (1) a Finnish speaking adult, aged 18-65 years; (2) diagnosed with a traumatic brain injury (diagnostic criteria ICD-10, S06.X, T90.5) in the University Hospital; (3) access to a TV, a computer, and the Internet at home; (4) not an active digital gamer (5 hours or less a week); (5) willing to participate in the study. Participants must have been discharged from the neurologic treatment period for traumatic brain injury for over 12 months before the commencement of the trial, and they may not have actively participated in cognitive rehabilitation during the 3 months prior to the trial. Written informed consent will be mandatory for acceptance into the trial. Exclusion criteria are as follows: (1) sensory, cognitive, or physical impairment (eg, severe cognitive impairment); (2) a deficiency restricting the use of computers or computer game control system unaided (eg, impairment in vision, severe astigmatism, hemiplegia, disorder in visuospatial perception, dysfunction of the central vestibular system); (3) apathy identified in previous neuropsychological evaluations; (4) diagnosed severe mental disorders (eg, schizophrenia or severe depressive disorders to be identified in medical records as the secondary diagnosis). RESULTS: The preparatory phase for the study is fulfilled. Recruitment started in June 2015 and finished November 2015. Results will be reported in 2016. CONCLUSIONS: The specific outcomes such as primary outcome measures were selected because they are widely used psychological tests and thought to be sensitive to changes in the cognitive functions related to TBI. TRIAL REGISTRATION: Clinicaltrials.gov NCT02425527; https://clinicaltrials.gov/ct2/show/NCT02425527 (Archived by WebCite at http://www.webcitation.org/6esKI1uDH).

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Recent evidence suggests that music-based interventions can be beneficial in maintaining cognitive, emotional, and social functioning in persons with dementia (PWDs). Our aim was to determine how clinical, demographic, and musical background factors influence the cognitive and emotional efficacy of caregiver-implemented musical activities in PWDs. In a randomized controlled trial, 89 PWD-caregiver dyads received a 10-week music coaching intervention involving either singing or music listening or standard care. Extensive neuropsychological testing and mood and quality of life (QoL) measures were performed before and after the intervention (n = 84) and six months later (n = 74). The potential effects of six key background variables (dementia etiology and severity, age, care situation, singing/instrument playing background) on the outcome of the intervention were assessed. Singing was beneficial especially in improving working memory in PWDs with mild dementia and in maintaining executive function and orientation in younger PWDs. Music listening was beneficial in supporting general cognition, working memory, and QoL especially in PWDs with moderate dementia not caused by Alzheimer's disease (AD) who were in institutional care. Both music interventions alleviated depression especially in PWDs with mild dementia and AD. The musical background of the PWD did not influence the efficacy of the music interventions. Our findings suggest that clinical and demographic factors can influence the cognitive and emotional efficacy of caregiver-implemented musical activities and are, therefore, recommended to take into account when applying and developing the intervention to achieve the greatest benefit.

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PURPOSE OF THE STUDY: During aging, musical activities can help maintain physical and mental health and cognitive abilities, but their rehabilitative use has not been systematically explored in persons with dementia (PWDs). Our aim was to determine the efficacy of a novel music intervention based on coaching the caregivers of PWDs to use either singing or music listening regularly as a part of everyday care. DESIGN AND METHODS: Eighty-nine PWD-caregiver dyads were randomized to a 10-week singing coaching group (n = 30), a 10-week music listening coaching group (n = 29), or a usual care control group (n = 30). The coaching sessions consisted primarily of singing/listening familiar songs coupled occasionally with vocal exercises and rhythmic movements (singing group) and reminiscence and discussions (music listening group). In addition, the intervention included regular musical exercises at home. All PWDs underwent an extensive neuropsychological assessment, which included cognitive tests, as well as mood and quality of life (QOL) scales, before and after the intervention period and 6 months later. In addition, the psychological well-being of family members was repeatedly assessed with questionnaires. RESULTS: Compared with usual care, both singing and music listening improved mood, orientation, and remote episodic memory and to a lesser extent, also attention and executive function and general cognition. Singing also enhanced short-term and working memory and caregiver well-being, whereas music listening had a positive effect on QOL. IMPLICATIONS: Regular musical leisure activities can have long-term cognitive, emotional, and social benefits in mild/moderate dementia and could therefore be utilized in dementia care and rehabilitation.

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BACKGROUND: The number of people eighty years of age and older in developed countries is increasing, with a concomitant increased demand for total hip replacement. We analyzed the outcomes of total hip arthroplasty for patients in this age group using data from the Finnish National Arthroplasty Registry. METHODS: Data from the Finnish Arthroplasty Registry on 6540 patients (6989 hips) who were eighty years of age or older at the time of a total hip arthroplasty, performed between 1980 and 2004, were evaluated with use of survival analyses. Factors affecting survivorship rates were sought, and the reasons for revision were identified. RESULTS: The mean age of the patients undergoing a primary total hip arthroplasty was 82.7 years. The mean longevity of 3065 patients who died following total hip arthroplasty was 5.1 years. With revision total hip arthroplasty for any reason as the end point, Kaplan Meier survivorship was 97% (95% confidence interval, 96% to 97%) at five years (2617 hips) and 94% (95% confidence interval, 93% to 95%) at ten years (532 hips). Of the 195 hip replacements that required revision, 183 had information on the reason for revision. Eighty-four (46%) were revised for aseptic loosening; thirty-six (20%), for recurrent dislocation; twenty-four (13%), for a periprosthetic fracture; and twenty-three (13%), for infection. Seven hundred and twenty-nine patients had undergone hybrid fixation (a cemented stem and a cementless cup). The survivorship of these replacements was significantly better than that for replacements with cementless fixation in 399 patients (p < 0.05). CONCLUSIONS: In patients who had a total hip arthroplasty when they were more than eighty years old, the prevalence of aseptic loosening was less than that encountered in younger patients, but recurrent dislocation, periprosthetic fracture, and infection were more common in this age group. Cementation of the femoral stem demonstrated better long-term results than cementless fixation, indicating that it may provide better initial fixation and, therefore, longer life-in-service.

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Movement-disabled persons typically require a long practice time to learn how to use a brain-computer interface (BCI). Our aim was to develop a BCI which tetraplegic subjects could control only in 30 minutes. Six such subjects (level of injury C4-C5) operated a 6-channel EEG BCI. The task was to move a circle from the centre of the computer screen to its right or left side by attempting visually triggered right- or left-hand movements. During the training periods, the classifier was adapted to the user's EEG activity after each movement attempt in a supervised manner. Feedback of the performance was given immediately after starting the BCI use. Within the time limit, three subjects learned to control the BCI. We believe that fast initial learning is an important factor that increases motivation and willingness to use BCIs. We have previously tested a similar single-trial classification approach in healthy subjects. Our new results show that methods developed and tested with healthy subjects do not necessarily work as well as with motor-disabled patients. Therefore, it is important to use motor-disabled persons as subjects in BCI development.

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We characterized features of magnetoencephalographic (MEG) and electroencephalographic (EEG) signals generated in the sensorimotor cortex of three tetraplegics attempting index finger movements. Single MEG and EEG trials were classified offline into two classes using two different classifiers, a batch trained classifier and a dynamic classifier. Classification accuracies obtained with dynamic classifier were better, at 75%, 89%, and 91% in different subjects, when features were in the 0.5-3.0-Hz frequency band. Classification accuracies of EEG and MEG did not differ.

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The main goal of this paper is to study the feasibility of a novel implantable micro-system able to record information about tendon sliding movements by using contactless measurement devices (magnetic sources and sensors). The system, named "Biomechatronic Position Transducer" (BPT), can be used for the implementation of advanced control strategies in neuroprostheses. After a preliminary analysis based on finite element model simulations, an experimental setup was developed in order to simulate the recording conditions (the sensors fixed to the bones and the magnetic sources placed on the tendons). In order to limit the number of implanted components of the system, a fuzzy Mamdani-like architecture was developed to extract the information from the raw data. The results confirm the possibility of using the presented approach for developing an implantable micro-sensor able to extract kinematic information useful for the control of neuroprostheses. Future works will go in the direction of integrating and testing the sensors and the electronic circuitry (to provide power supply and to record the data) during in vitro and in situ experiments.

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STUDY DESIGN: An open-label study was conducted. OBJECTIVE: To evaluate the efficacy and safety of infliximab, a monoclonal chimeric antibody, against tumor necrosis factor-alpha (TNFalpha) for the treatment of severe sciatica. SUMMARY OF BACKGROUND DATA: Evidence from animal studies indicates that TNFalpha plays a role in the pathophysiology of sciatica. Anti-TNFalpha therapy has not been previously evaluated in sciatic patients. METHODS: In this study, 10 patients with disc herniation-induced severe sciatica received infliximab (Remicade 3 mg/kg) intravenously over 2 hours. The outcome was assessed at 1 hour, 1 week, 2 weeks, 1 month, and 3 months after the infusion and compared to historical control subjects consisting of 62 patients who received saline in a trial of periradicular infiltration for sciatica. Leg pain was the primary outcome, with more than a 75% decrease from the baseline score constituting a painless state. Fisher's exact test and repeated measures analysis of variance were used for statistical analysis. RESULTS: At 1 hour after the infusion, leg pain had decreased by 50%. At 2 weeks, 60% of the patients in the infliximab group were painless, as compared with 16% of the control patients (P = 0.006). The difference was sustained at 3 months (90% vs 46%; P = 0.014). Infliximab was superior over the whole follow-up period in terms of leg pain (P = 0.003) and back-related disability (P = 0.004). At 1 month, every patient in the infliximab group had returned to work, whereas 38% of the control subjects still were on sick leave (P = 0.02). None of the patients treated with infliximab underwent surgery during the follow-up period. No immediate or delayed adverse drug reactions and no adverse effects related to medication were observed. CONCLUSIONS: Anti-TNFalpha therapy is a promising treatment option for sciatica. There is an urgent need for a randomized controlled trial to evaluate whether thesepromising early results can be confirmed.

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